Editor’s note: For seniors, exercise is an important way to prevent injury and retain independence. But it can be difficult to come up with a routine that works for you. Frank Hernandez of the Central Valley town of Delano solved that problem by turning to rollerblading. He’s now 72 and shows no sign of stopping. We visited the skatepark with Hernandez as part of our community health series Vital Signs.

By Frank Hernandez

When I first started I would rollerblade the skate paths, then I said, “I need more than this.”

I used to look at the X-Games, and I saw the rollerbladers back then in the 90’s, and I said, “Oh, I’m going to do that someday.”

I’ve had a lot of falls, a lot of injuries: strained my knee really bad, bruised my rib cage twice, shoulder strain three or four times, face-plant once. But I’ve never had a broken bone, so I’m pretty lucky. I’m not really stubborn, I just think that if I want to do something I can do it.

Hernandez says the secret to his health is a good breakfast, frequent exercise, and most of all, his wife’s support. “She keeps me in line,” he said. They met in middle school. (Jeremy Raff/KQED)

I grew up in Delano. My grandmother raised us in the mid-1940s. At that time, we had the west side of town and the east side of town — the east side of town was the more affluent. I didn’t know whether I was smart enough to go to college, or was I just a dumb kid from the west side?

There’s nothing wrong with being a fieldworker, but I didn’t want to be a fieldworker. I saw some of the people that did field work, and some of them looked like they were very old, but they weren’t.

My wife [and I] think back now and we say, “Gee, what would have happened if we spent our whole life doing that? Do you think that would have affected our health?” I think so.

I was an accountant for 34 years. I was the first Mexican-American accountant for the company.

My last 30 years of work, I worked 50 to 70 hours a week. The stress got to me. The doctor said, your system’s all messed up. You’re working too many hours, number one, and if you work that many hours, then get your heart rate up. Do something to get that blood flowing. From that point on, I made sure I always did a little bit of physical fitness.

Frank Hernandez, 72, slides down a rail at a skatepark in Delano, Calif. As a teenager, he picked grapes just a few miles from this skatepark before moving away and becoming an accountant. (Jeremy Raff/KQED)

When I was 62, I told my company I was going to retire. Six months after I retired, I got the bad news from my doctor. He called me and told me, “Frank, you have cancer.” Prostate cancer.

After I had my surgery, the first thing I told my doctor was, “Well, how long before I can rollerblade?”

I’m sure there are other people out there my age that do this. But a lot of people say, “What’s going to happen? One day, you’re going to get hurt, and you’re going to be crippled!” But I enjoy skating. It’s something that I like to do. Like I say, it’s a natural high for me.

I would like to continue rollerblading until I’m done. Until I die.

Jeremy Raff reported this story.

]]>http://blogs.kqed.org/stateofhealth/2014/12/19/video-meet-frank-hernandez-rollerblading-at-72/feed/0Frank FaceHernandez says the secret to his health is a good breakfast, frequent exercise, and most of all, his wife's support. "She keeps me in line," he said. They met in middle school.Frank MakioFrank Hernandez, 72, slides down a rail at a skatepark in Delano, CA.Older Californians’ Outlook for Long Term Carehttp://blogs.kqed.org/stateofhealth/2014/11/24/older-californians-outlook-for-long-term-care/
http://blogs.kqed.org/stateofhealth/2014/11/24/older-californians-outlook-for-long-term-care/#commentsMon, 24 Nov 2014 19:42:07 +0000http://blogs.kqed.org/stateofhealth/?p=22674The way the medical system talks about aging often gets it all wrong.

That’s what Bruce Chernof, a geriatric physician and head of The Scan Foundation in Los Angeles, wants you to know.

“People define themselves by the function they retain, not the function they’ve lost,” he says.

That means there’s a huge disjoint between the words older Americans use most frequently to describe the kind of care they want in later life (words like “choice,” “independence,” “dignity”) and the most common words doctors rely on (“palliative care,” “geriatrics,” “advanced directive,” “donut hole”).

Chernoff, who is also the former director of the Los Angeles County Department of Health Services, is on a mission: getting health professionals to think about how to engage people around aging outside of the traditional medical model.

While the medical system is largely focused on cure and safety, Chernof argues that there should be new metrics. Including those that measure things like functioning and ability to accomplish things by oneself.

Chernof argues that there should be new measures. Including markers for ability levels and independence.

“There are basic functions,” Chernof says, “like dressing, bathing, feeding, and toileting. And then there are instrumental functions like transportation and cooking.”

He says it is very important to go beyond medical diagnoses and to start collecting data on functioning.

“Chasing a blood sugar level to perfection in a 90-year-old who has outlived three primary care doctors and really just wants to wake up and have a donut with their coffee — we need to work with that,” says Chernof.

Chernof says complicating the long term care situation in California is the fact that this is a very diverse state.

“The situation in rural California looks very different than in San Francisco or the East Bay. ‘One size fits all’ solutions will be problematic because this looks different in different communities,” says Chernof.

In 2014, Chernof’s Scan Foundation and the Commonwealth Fund produced a scorecard on long term care capacity that was compiled by the AARP’s Public Policy Institute. It was the second annual scorecard and ranked states on criteria like affordability and access, choice of setting and provider, quality of life and quality of care, and support for family caregivers.

California ranked ninth in the U.S. According to the report that makes it “a leading state in an imperfect system.”

How can California raise its score further?

California gets its highest rank on the scorecard (#2 in the U.S.) for offering people choice. Many older Americans prefer not to enter institutionalized care as they age. Recognizing that, California spends more Medi-Cal funding on services that allow people to stay in their homes versus on institutional care. Here, 56 percent of all Medi-Cal long term service dollars go to the community. Still, the state lags behind top-ranked New Mexico where 65 percent of Medicaid long term care dollars go to the community.

San Francisco, itself, has a national model in this area: PACE — Program of All-inclusive Care for the Elderly. The program is centered on the idea that it is better for individuals over 55 with chronic conditions to live in their communities rather than in institutions. PACE was pioneered at the city’s On Lok Lifeways center and has now been incorporated as a model in the national Medicare program.

On the flip side, California does not rate so well when it comes to quality of life and quality of care, and for the support it offers family caregivers.

One disturbing statistic as far as quality measures in the state is around bedsores. The report found the rate of pressure sores among California’s nursing home residents is double that of Hawaii, the best-performing state.

There are nearly six million unpaid caregivers in the state, mostly family and friends. Their contributions to care are valued at nearly $47 billion annually. California offers 12 weeks per year of job protected leave which is the minimum established by the federal Family Medical Leave Act. Meanwhile top-ranked Washington, D.C. provides 16 weeks family leave and 16 weeks of medical leave every two years.

Finally the report also suggests that California could safely transition many more individuals from institutional settings to the community. Eleven percent of California nursing home residents have low-care needs as compared to 1 percent in Maine, the top-ranked state. The benefits of making this transition happen include higher qualities of life and reduced costs.

The scorecard recognizes that the state is undergoing a huge transition — moving many seniors who are eligible for both Medi-Cal and Medicare into a new program called Cal MediConnect that is receiving mixed reviews.

With the number of adults in the state over 65 expected to double between 2000 and 2030, experts say now is the time to get this issue right.

Rachel Dornhelm wrote this story through a journalism fellowship from New America Media and the Gerontological Society of America, supported by AARP.

Now “Villages” — yes, with a capital V — are sweeping the U.S., looking to redefine how people age in their communities.

The Village movement brings together older adults who want to age in their homes independently, but believe it will be too hard to do so, unless they have some support. These virtual villages link independent living seniors together. Members offer support to each other as they are able, and ask for support when they need it through an organized system.

Half of all villages in the U.S. started in the last three years. Because they are such a recent phenomenon, there have not been many studies about their outcomes.

Now, the initial results from a retrospective, three year study from UC Berkeley find support for many of the movement’s positive claims. Butthe data, being presented at the Gerontological Society of America conference, also raises flags about the communities’ diversity and sustainability.

“People, by and large, report that the village has made a substantial difference in their life,” says Andrew Scharlach, a professor at UC Berkeley and the principal investigator of the ongoing study that includes in-person interviews with 300 residents at nine California villages.

The study has shown that over time village members’ desire to move out of their home and community decreased.

Also, 55 to 80 percent of respondents reported a jump in quality of life. The more involved they were with the village, the higher the impact.

But, Sharlach says, there are some caveats.

People in the study self-reported big gains in social connections — knowing more people, getting out of the house more, and interacting with people more than they used to.

But when the researchers looked at data from the 133 people they followed over the course of 12 months, there was no evidence that the number of interactions or social connections these people had, had actually changed.

“If you ask, the first day of the village, ‘How many people do you know? How often do you get out of the house? How many social activities are you participating in?’ and then you come back a year later and ask the exact same questions,” says Sharlach, “there’s not a significant difference.”

He says it’s possible one year may be too soon to see significant changes in numbers, or the questions may not be capturing the growth areas for people. Another possibility is that people join the village during transitions in life and their social circle doesn’t grow, it just shifts.

Village participants’ health outcomes are another area policy experts are eager for data about. Sharlach’s team is looking at changes over time in incidents of falls, emergency department visits and hospital admissions. But he says that data is still being processed.

The weakest points the study found were around diversity and sustainability.

Villages are 94 percent white, according to studies. If they are going to be a model to serve a greater aging population, Sharlach says, the challenges that communities have reflecting the whole population need to be addressed.

He says those could include some cultural barriers. The village model is aimed at helping individuals age in place, but in some cultures families and other communities are inextricably linked to their elders. That means adapting the model to serve existing communities.

Right now, though, given that they are largely white, Sharlach says that raises questions. “invite someone who is African-American, or Latino or Asian Pacific Islander to join a village,” he says. “And they come to a meeting that is based on social connections and these aren’t people who are naturally part of their social connections, are they going to want to join this club?”

Another challenge the study found was the sustainability of Villages.

Nationally, and also in California, about 50 percent of the budgets are covered by membership dues, but the other 50 percent has to be raised.

“Whether that’s through contracts and grants or through the government, [in order to succeed for the long term] that’s the area that really needs to be figured out,” says Sharlach.

The city of San Francisco stands out as a government that has supported its two villages. In February 2013 the city gave $50,000 each to the San Francisco Village and the NEXT Village. But these grants are the exception, not the rule.

Sharlach says the study shows there are great benefits to be had from the Village model, but the challenges suggest the model really needs to be models, plural, to serve the many communities that could take advantage of them.

The UC Berkeley study followed residents at nine communities in California. Most were suburban but it included the rural Community Connections program in Plumas County and the urban San Francisco Village were also included. The remaining study sites were Ashby Village (Berkeley), Avenidas (Palo Alto), Santa Barbara Village, Wise Connections (Santa Monica), Westchester Playa Village, Real Connections (Claremont-Pomona), and Tierra Santa in San Diego.

Rachel Dornhelm wrote this story through a Fellowship from New America Media and the Gerontological Society of America, supported by AARP.

Gov. Jerry Brown signed into law Monday a bill imposing a 100-fold increase in the top fine for violations of state regulations at assisted-living homes for the elderly.

The top fine will now be $15,000, for violations causing death or serious injury, up from $150.

The relatively low fines were highlighted in a series of stories produced last year by the CHCF Center for Health Reporting and the U-T San Diego. The series focused on 27 deaths and hundreds of injuries at homes in San Diego County caused by abuse and neglect.

The bill to increase fines, co-authored by Assemblyman Brian Maienschein, (R-San Diego), was amended during the legislative process to allow a four-step appeals process. Also, a proposal to boost fines for some lesser offenses to $1,000 from $150 was removed from the bill amid lobbying from smaller assisted living homes.

Brown’s signature on the fine increase came one day after he signed nine other bills tightening state oversight of the more than 7,500 assisted-living homes in California, marking the state’s most sweeping overhaul of the industry in nearly three decades.

For the first time, assisted living residents will have a statutory bill of rights like the one protecting nursing home residents.

The homes’ staffs also will face stiffer training requirements, and owners will pay higher licensing fees. A staff member with CPR training must be present at homes at all times, and operators will be prohibited from punishing employees who call 911 to get emergency care for sick residents.

Brown’s signature on the reform package is a major victory for assisted living residents, said Patricia McGinnis, executive director of California Advocates for Nursing Home Reform, the state’s largest advocacy group for long-term care residents.

“We look at it as a good start,” said McGinnis. “But we’re not finished by any stretch of the imagination. And I don’t think the legislators are, either. I think they like the fact that they’re going to be changing people’s lives on an immediate basis.”

Many of the assisted-living bills that Brown did sign were backed by McGinnis’s group and the California Assisted Living Association, the state’s largest industry association.

Both groups had pulled their support of the bill to raise fines after it was, in their view, weakened.

Four San Diego legislators played key roles in the reform effort: Democratic Assembly Speaker Toni Atkins and Democratic Sen. Marty Block; and Republican Assembly members Brian Maienschein of San Diego and Marie Waldron of Escondido.

Brown signed Atkins’ bill last month requiring that all assisted living facilities carry liability insurance. Brown signed Block’s two bills Sunday.

Block said he intentionally chose the bill name SB-911 for one of his measures, which will protect facility employees who call for emergency care for sick residents. Some employees have said they fear calling 911 because managers say it reflects badly on a home’s record, he said.

The same bill raises the training mandate for administrators to 80 hours from 40. Brown also has signed a parallel bill, authored by Assembly Member Wesley Chesbro, D-Arcata, requiring more training for staff caring for residents, including those with dementia.

Sally Michael, president of the industry group California Assisted Living Association — which, along with McGinnis’ group, supported a number of the reform measures — said it is pleased by Brown’s actions, particularly his signing of the Chesbro bill and Block’s SB 911.

“These bills increase the number of hours required for assisted living caregiver and administrator training. They also improve the administrator testing process by making it more rigorous,” Michael said.

Block initially proposed a 30 percent increase. He said Monday that for now, the 20-percent hike is enough to provide much needed funds to the Department of Social Social Services, which regulates assisted living homes.

“This will be a game changer in terms of funding more inspections and other services,” Block said.

The other assisted living bills that Brown signed Sunday:

SB 895, mandating that homes fix problems found during state inspections within 10 days of being notified (Sen. Ellen Corbett, D-Hayward).

SB 1153, giving state regulators the power to halt new admissions to an assisted living home that has not immediately fixed major violations (Sen. Mark Leno, D-San Francisco).

The CHCF Center for Health Reporting partners with news organizations to cover California health policy. Based at the University of Southern California’s Annenberg School for Communication and Journalism, the Center is funded by the nonprofit California HealthCare Foundation.

A federal lawsuit against two Watsonville nursing homes may offer a new approach to dealing with the persistent problem of such facilities overmedicating their residents.

The lawsuit details multiple cases when the government says these drugs were inappropriately administered to patients. Watsonville is northeast of Monterey, in Santa Cruz County.

For instance when an 86-year-old man identified in the lawsuit as Patient 1 was admitted to Country Villa Watsonville West, he could speak clearly and walked in under his own power. Within days the facility began giving him Haldol and Risperdal, drugs used to treat schizophrenia and bipolar disorder, and he became bedridden, stopped eating and developed bedsores and infections.

“Within days he declined precipitously, to the point where he was read his last rites in the hospital,” says Tony Chicotel, a staff attorney with California Advocates for Nursing Home Reform who represented the man and his family in a private suit that was settled out of court.

“He subsequently recovered,” says Chicotel, “but all this had been done without his family’s knowledge, without his informed consent, without real good clinical indications for the use of the drug.”

Antipsychotics like Risperdal and Haldol come with so-called black box warnings that say they could hasten death in elderly patients or people with dementia. Nevertheless, about a fifth of nursing home patients nationwide are prescribed antipsychotic drugs.

The U.S. attorney for Northern California declined to comment on the lawsuit, but it claims that the two nursing homes provided “grossly inadequate, materially substandard and/or worthless services.” Meanwhile, the nursing homes received about $20 million from Medicare and Medicaid for those services. So now the government wants its money back, and then some.

“Under the False Claims Act, the government can ask for triple damages,” explains Kelly Bagby, a senior attorney with the AARP Foundation. The nursing homes also could be fined, she says, for each incidence of filing a false report.

“So every time they submitted a form that said, ‘Here is Mrs. Jones’ needs’ and Mrs. Jones’ needs were different than that, each one of those forms is a violation,” says Bagby.

In a statement, the companies that own the two nursing homes called the charges “untrue and without merit.” They also filed their own lawsuit blaming the company they hired to manage the two facilities.

Deborah Pacyna, public affairs director for the California Association of Health Facilities, says that in the past couple years the federal government, in partnership with organizations like hers, has succeeded in reducing the use of antipsychotic drugs in nursing homes.

“But a lot of the regulators, a lot of our critics seem to be ignoring the fact that antipsychotics are being widely prescribed to patients who have dementia who are living at home, who are in the hospital or who are in assisted living settings,” Pacyna says. “Skilled nursing (homes) represents a fraction of those that have been impacted by this practice, yet we remain the focus.”

Bagby, the AARP attorney, would like to maintain that focus, and thinks this lawsuit can help do that. “If you’re going to hit their bottom line, that’s really where you change behavior.”

Bagby adds that with antipsychotic drugs still so widely prescribed for nursing home residents, there’s the potential for more cases like this one across the country.

]]>http://blogs.kqed.org/stateofhealth/2014/09/06/watsonville-nursing-home-lawsuit-may-drive-effort-to-reduce-overmedication/feed/0Picture taken on January 15, 2012 in Lil(Philippe Hugue/AFP/Getty Images)Two Women on a Mission to Reform Assisted Living in Californiahttp://blogs.kqed.org/stateofhealth/2014/09/05/two-women-on-a-mission-to-reform-assisted-living-in-california/
http://blogs.kqed.org/stateofhealth/2014/09/05/two-women-on-a-mission-to-reform-assisted-living-in-california/#commentsFri, 05 Sep 2014 22:03:06 +0000http://blogs.kqed.org/stateofhealth/?p=21266

Christina Selder and Chris Murphy of Consumer Advocates for RCFE Reform in San Diego conduct their crusade from a modest home office. (Rachael Myrow/KQED)

Many of us dream of starting a revolution. Few of us make it happen. One of the most dramatic stories of the last year belongs to a loose collection of activists, working to reform assisted living oversight in California. Together with lawmakers, these activists launched 17 bills in Sacramento, 12 of which passed, 2 of which have become law, so far.

It’s a big story, but let’s break off one piece, involving a couple women in San Diego with a passion for raw data, strong coffee and home-baked muffins.

About a decade ago, Chris Murphy’s mom was suffering from Stage 4 ovarian cancer. She couldn’t live on her own. Someone suggested Murphy check out an assisted living facility, and so she took a tour.

“This is really a cool place,” Murphy says she thought at the time. “Maybe my mother would like to live here. I would like to live here. I was sucked in by the chandeliers, and by the garden, and by the apparent appearance of the facility.”

Sitting in her home office today, with a fan going to hold off the summer heat, Murphy declines to go into detail about how, exactly, her mom died. Murphy eventually sued and settled.

But she continued to stew over it.

“I didn’t know that there was a public record that I could review,” she says. “I didn’t know that the facility had had a wrongful death lawsuit against it. That was not in the public record, even when I was able to review the public record, after the lawsuit. I figured that because they were licensed that the state had some meaningful oversight of this facility, only to discover that it was haphazard, in my view, at best.”

Murphy was retired from a career in defense contracting, but she decided to go back to school at San Diego State and study gerontology — the social and psychological aspects of aging. That’s where she met Chrisy Selder. Selder was doing her thesis on the idea that people who don’t need round-the-clock, licensed nursing care would be happier in homier assisted living — which happens to be significantly less expensive than skilled nursing care. It’s a commonly accepted idea in California, where the number of assisted living facilities has doubled in the last 25 years. But Selder’s thesis fell apart after she worked in a few facilities and interned in the local ombudsman’s office. The more research she did, she says, the less she thought that assisted living really was a good alternative to nursing homes.

Recognizing a kindred spirit, Selder joined Murphy to launch a non-profit called Consumer Advocates for RCFE Reform, or CARR. (An RCFE is regulator-speak for Residential Care Facilities for the Elderly. Most of us call them “assisted living facilities.”)

“There were a lot of things that I learned in that process,” Murphy says, “that if I had known at the front end, I may have made better placement choices for my mother. And then I decided I had a lot of information that could be leveraged for the consumer.

What CARR did was create an online database of facilities and public records to give consumers “immediate access to a facility’s public documents,” it says on CARR’s website. Before CARR, this online access did not exist.

There are more than 700 facilities on CARR’s website today, including about 30,000 public documents “harvested” by Murphy, Selder and volunteer student interns from San Diego State’s programs in criminal justice, gerontology, social services, and public health.

Except for the website administrator, everyone at CARR is a volunteer. It’s going to take them a long time to get the whole state catalogued. So far, they’ve got San Diego and Imperial Counties, parts of Orange County, and several small, rural counties in Northern California. They’ve also got CalVet facilities. Given their non-existent public relations department, the database was a bit of a trade secret, until the day a health reporter named Deborah Schoch did a Google search and turned up CARR’s site. Schoch is with the Center for Health Reporting at USC, and she spotted the raw material for a series of investigative reports.

“They went in and hand scanned thousands and thousands of documents,” Schoch says. “We were able to use those to detect certain homes and then went in and scanned our own records, and found more homes like that. But (CARR) gave us an entry point. I have to tell you, some of these folders are 3 inches thick, and there may be two of them, and they’re very difficult to navigate. You just have to go through it page by page by page. There’s nothing that says right up front ‘somebody died here.'”

Schoch joined forces with UT San Diego to detail 27 deaths in San Diego County assisted living — deaths caused by neglect and abuse. The series they published, “Deadly Neglect,” was one of several media exposes that inspired those 17 bills in Sacramento.

You might think it odd CARR collects the same data the state does, but if you want to get at state data, you have to call your local Department of Social Services office, and wait for staffers to pull the data on the facilities you’re interested in. Murphy says people don’t realize how hard it is to research — until time is tight and the stakes are high.

“You’re going to take off three days worth of work,” Murphy says. “You’re going to make a California records act request. The state of California is going to tell you when you can come in and look at that file.” Meanwhile she says, your dad is leaving the gas on after he cooks. Or the facility he’s living in now has issued a discharge notice with a deadline.

That, and the files are edited to remove data considered “non-public” by somebody in Sacramento. Schoch, who put in a Public Records Act request for some facility files, discovered some of the records removed included those detailing injuries and deaths.

CARR’s database makes all the inspection, complaint, and civil penalty reports it collects available online for a small fee ($25 a month). Murphy says they have about 30 subscribers at any given time, including placement agencies and attorneys, as well as families looking to place their parents.

“We needed a little bit of revenue. And a little bit of revenue is all we’re getting!” Murphy says and explodes into laughter.

Over the years, Murphy and Selder’s jaundiced opinions have only hardened. From their vantage point, elbow deep in documents, the profit motive leads managers to cut corners. Regulations are enforced unevenly. The problems afflict facilities of all sizes, not just the big, corporate ones. Lobbyists in Sacramento will argue small facilities shouldn’t be regulated as tightly as large ones. Selder disagrees. “There’s no cluster. [Facilities with] 6 beds are having just as much problems as the125 beds.”

Murphy and Selder don’t rate facilities, because, they say, individual needs are so different. They prefer to upload raw data. This year, they did something they’ve never done before: sponsor a bill. AB 1523, now signed into law by Gov. Jerry Brown, mandates all assisted living facilities carry liability insurance. While some owners of small facilities protested they won’t be able to afford the coverage, there’s wide agreement consumers have little recourse to address serious concerns given what many describe as light oversight from state regulators.

In a statement CARR issued after the governor signed AB 1523 into law, Murphy and Selder wrote that they hope the law encourages insurance companies to “weed out the poor performers” the state hasn’t managed to, and lead to the closure of facilities that are “un-insurable.”

“I was absolutely shocked to learn that facilities didn’t carry liability insurance,” Atkins says. “I had a hard time understanding how any business, in this day and time, and particularly a business that deals with frail, elderly people, could not have liability insurance.”

Speaker Atkins says the evidence presented by “the Chrises” helped build a data-driven case in Sacramento for substantive reform. “Typically, as a legislator, you want to see the data,” Atkins says. Murphy and Selder, she says, “Set about compiling that data, and putting it front of people.”

For those who wanted to see substantive reform of assisted living facilities in California, it’s not clear yet how many of the original 17 measures will make it into law, how many were de-fanged in 11th hour rewrites. Schoch has drawn up a handy scorecard.

“A lot of it had to do with cost,” Speaker Atkins says about what killed or altered reform bills in the waning days of the legislative session. She offers up AB 1454 by Assemblymember Ian Calderon (D-Whittier) as an example. It would have mandated annual, unannounced inspections of all licensed community care facilities, including assisted living homes. This would require more staff at the Department of Social Services, and thus, more money in the agency’s budget. The Brown Administration did approve a bigger budget for DSS this year, but it’s not a given it would be enough to guarantee annual visits. Atkins holds out hope for future budget boosts, though. “California’s making a turnaround as it relates to health and human service issues, but it’s taking awhile,” she said.

Murphy worries about how those bills that do make it into law will be interpreted by regulators. “If it’s not clearly stipulated within the bill, then it’s left to the regulators, and then the regulators are going to come up with whatever they come up with.” She wants to see the California Department of Social Services set up stakeholders meetings across the state, to ask what families and activists want to see happen next.

Taking some fresh air in the courtyard at Westchester Villa, an assisted facility in Inglewood. (Rachael Myrow/KQED)

Last Thursday, August 14, was the day that bills still in the state Senate Appropriations Committee sank or swam. The Senate Appropriations Committee is where bills costing $150,000 or more go for consideration. If bills make it out of this committee, then bills are still in play and could make it to the governor’s desk, albeit with potential amendments along the way. If not, they die.

Going into the home stretch of this legislative session, 16 bills were on the table that, altogether, constituted the first major overhaul of the assisted living industry in nearly 30 years.

Two have already made it to the governor’s desk. AB1523 mandates liability insurance for all assisted living facilities. Advocates say liability insurance is one of the best ways to improve conditions in the industry. Operators whose violations make buying insurance too expensive will be simply forced out of business. The industry group California Assisted Living Association supported AB1523. AB1572 mandates facility operators allow and support resident and family councils at assisted living facilities. CALA supported that one as well.

Most of the rest of the bills are still swimming. But what about the bills that died?

AB1571 (Eggman D-Stockton) would have created a more robust online consumer information system than the one currently offered by the Department of Social Services.

“It is very disappointing,” says Pat McGinnis, executive director of California Advocates for Nursing Home Reform, one of the key advocacy organizations sponsoring legislation this year. McGinnis says that there are more than 7,500 licensed facilities in California, “and absolutely no way for consumers to compare one facility with another. It will be impossible for consumers to try to look up 348 [facilities] in Alameda County, for example, to try to see what violations, deficiencies, et cetera, they might have.”

“I am not at all finished with this issue,” says the bill’s author, Assemblywoman Susan Eggman (D-Stockton). Though she says the DSS has already made changes to its website in response to AB1571, Eggman says she is considering reintroducing similar legislation in the next session. The DSS declined to comment.

AB1454 (Calderon D-Industry) would have required every facility licensed by the Department of Social Services to be subject to annual, unannounced inspections. DSS licenses many different types of facilities, not just assisted living facilities. Currently, state law requires DSS to visit a facility every five years, barring a complaint which generates a separate visit. The agency says in practice it has an investigator visit about every 2 and a half years.

Bill watchers say two concerns appear to have spiked this bill. For one thing, AB1454 would have changed the inspection frequency for every type of facility DSS visits. For another, that would cost a pretty penny: $20 million, by one state estimate.

In a written response, Assemblyman Ian Calderon said, “Although the Legislature provided an increase in funding to the Department of Social Services in the 2014-2015 Budget to protect our children and elderly, annual inspections continue to be urgently needed as part of the oversight process. Without increasing the frequency of unannounced visits, our state will continue to put our most vulnerable populations – children and elderly – at risk.”

But there’s another bill that addresses this issue, in part. SB895 (Corbett D-Alameda) would phase in unannounced annual visits for assisted living facilities only, by July 1, 2018. That passed out of the Senate Appropriations Committee with amendments.

Finally, AB1554 (Skinner D-East Bay) would have required the DSS to investigate complaints that alleged physical or sexual abuse, or imminent physical danger, at assisted living facilities within one working day, instead of 10 — and report to the complainant promptly.

Assemblywoman Skinner remarks the bills that made it out of the Senate Appropriations Committee put the onus on the industry itself, as opposed to the DSS.

“My frustration is, if we have higher expectations on the facilities, if we don’t have responsibility of the agency to enforce, then how are we going to feel assured that these facilities are complying?” Skinner is termed out, so she won’t introduce a similar bill next legislative session. But she adds, note how many legislators were involved in trying to reform assisted living facilities. This issue, Skinner says, isn’t going to go away.

Rachael Myrow contributed to this report.

]]>http://blogs.kqed.org/stateofhealth/2014/08/18/the-assisted-living-reform-bills-that-died/feed/1RS11379_photo-scrTaking some fresh air in the courtyard at Westchester Villa, an assisted facility in Inglewood. (Rachael Myrow/KQED)Are The Proposed Assisted Living Reforms in California Enough?http://blogs.kqed.org/stateofhealth/2014/08/12/are-the-proposed-assisted-living-reforms-in-california-enough/
http://blogs.kqed.org/stateofhealth/2014/08/12/are-the-proposed-assisted-living-reforms-in-california-enough/#commentsTue, 12 Aug 2014 12:50:56 +0000http://blogs.kqed.org/stateofhealth/?p=20618

A “crime book” maintained by the San Diego advocacy group Consumer Advocates for RCFE Reform. (RCFE is short for Residential Care Facility for the Elderly.) This book contains cases of what CARR calls “egregious neglect” at San Diego assisted living facilities. (Rachael Myrow/KQED)

Over the last 25 years, the number of assisted living facilities in California has nearly doubled. The homes are intended to care for relatively independent, healthy seniors, but that doesn’t describe a lot of the people living in them today.

“There’s been a seismic shift in the population they serve,” says Deborah Schoch of the California HealthCare Foundation Center for Health Reporting. Schoch says the system was set up to meet the needs of people who could use some extra help with the tasks of daily living –- and it does. But many of those people need a lot of help.

The system, she says, is caring for people “who are frail, who may have dementia, who may be wheelchair bound, who may not be able to turn on their own in bed.”

Assisted living facilities are not designed to deliver skilled nursing care, and they do not typically have people with those qualifications on staff. There are no staff-to-resident ratios or many of the other rules that govern nursing homes. While many assisted living facilities do a fine job of delivering care, others are overwhelmed –- or worse. Schoch was the lead reporter for a series called “Deadly Neglect” that detailed 27 deaths in San Diego County assisted living facilities from abuse and neglect.

“I worked with UT San Diego, and we were able to get access to a lot of inspection reports: deaths, injuries, elder abuse, people left on the floor for 48 hours in assisted living facilities in San Diego County.”

She’s since come out with more stories detailing more troubling incidents, but that first series had a politically explosive effect. In San Diego, Supervisors voted to fund a special unit in the District Attorney’s office to target crime in the facilities.

In Sacramento, where regulations haven’t changed much in close to 30 years, lawmakers held hearings featuring reform advocates like Aaron Byzak, who started a group called “Hazel’s Army” after his grandmother Hazel died in assisted living. “If somebody parked in my grandmother’s disabled parking lot illegally, they’d be fined $450,” he told reporters in the state capitol. “But they kill her, and it’s $150.”

Lawmakers were also keenly aware of recent headlines from Castro Valley, where 14 bed-ridden residents were discovered abandoned after the state ordered the facility closed. It turned out the operators had a long list of violations.

You’ll get no argument from the agency charged with oversight of these facilities that it’s time for a revamp. A number of recommendations made in its last annual budget proposal mirror reform bills now pending in the legislature, such as raising the $150 maximum fine to $15,000, and upgrading the online database available to the public. That’s not all. Pat Leary is the Chief Deputy Director of the California Department of Social Services.

“They’re going to create a medical expertise unit, with a nurse,” Leary said. “We’re establishing a corporate accountability unit. There are a number of these facilities that are owned by corporations that are making decisions on a statewide basis. But the way that we track facilities is on a one-facility-at-a-time basis — we’ve been missing trends.”

Two women in San Diego were so frustrated with the lack of data and analysis, they created their own non-profit, and their own database for roughly 700 assisted living facilities in San Diego and Imperial Counties, as well as rural Northern California. CARR, the Consumer Advocates for RCFE Reform, (RCFE stands for residential care facility for the elderly) has managed to do what the state hasn’t yet – build a publicly accessible online database with 30,000 documents, including inspection, complaint, and civil penalty reports. Their documents formed the basis of “Deadly Neglect.”

“There are a number of cases where facilities will have repeat noncompliance meetings for atrocious activities,” Selder said.

Without providing its name, she mentions a facility CARR uses as an example.

“This particular facility had one resident who was left on the floor in their apartment for more than 24 hours and bled to death,” she said. “Same facility, a dementia resident who was unable to consent to have sexual relations with another resident but that repeatedly went on. There was a culture of fear among the staff, and so they weren’t cooperating during the investigation with Department of Social Services. That was the third one for this facility. Now, this facility remains open today. There’s no caution tape on the door.”

Her partner in CARR, Chris Murphy, chimes in. “I mean it’s almost like ‘what do you have to do to get closed?'”

They’ve developed some strong opinions after reviewing so many DSS reports. For instance, despite the claims of some that the worst abuses are likely to be more common in big facilities, especially those owned by corporate chains, Selder and Murphy say small homes are just as likely to fail their residents.

Both Murphy and Selder have degrees in gerontology. Both say they’re heartened by all the legislation in Sacramento, especially the bill they sponsored, AB 1523, requiring all facilities to carry liability insurance. [UPDATE: That bill passed, and Governor Jerry Brown signed it into law.] But Murphy worries about the fine print on all the legislation. “If it’s not clearly stipulated within the bill, then it’s left to the regulators, then the regulators are going to come up with whatever they come up with. So I would hope that they get serious about having stakeholders meetings, using all of the expertise that’s available in this state.”

Selder worries lawmakers are tweaking a system that is fundamentally dysfunctional. If a growing number of elderly need medical care, Selder says, maybe they shouldn’t be in assisted living. Or maybe assisted living should deliver tiered levels of care, with tiered levels of regulation. But that’s not the discussion on the table in Sacramento – at least, not this year.

“We are behind the curve,” Selder says. “Other states have rating systems. Other states have assisted living regulated under the Department of Public Health. We’re not there. We’re not even talking about it in the right way yet.”

Stacy Siriani’s father suffered a serious injury while in an assisted living facility in San Diego. (Rachael Myrow/KQED)

When families place a loved one in an assisted living facility, there’s an expectation that if something goes wrong, there will be consequences. Mistakes will be addressed. If crimes are committed, they will be prosecuted. Or at least investigated by law enforcement.

But that’s not always what happens.

Take the case of Stacey Siriani of San Diego County. Her experience with assisted living began four years ago when she got an awful phone call from Houston. Her father was involved in an auto accident that left him brain damaged.

“It was very tough,” she recalls. Siriani is an only child; her father is a widower. There was nowhere else to turn for support.

First, her father spent some time in a Texas hospital trauma unit, and then in rehab. After that, Siriani moved her dad to California, into an assisted living facility so close to her home in Carlsbad that she could visit two or three times a day.

Just as important, it had a memory care unit, meaning extra supervision — and locked doors to block wandering residents. She’d spied the facility driving past, and really, that was the extent of her research. That, and a tour.

“At that time, I didn’t know what citations were,” she says. “I just went off the marketing lady that takes you on the tour and promises you the world, just like they do everybody else.”

Her dad didn’t qualify for public assistance, so this cost him about $3,300 a month, out of pocket.

A few months later, Siriani got another awful phone call. A staff member from the facility said her father had fallen and cut his chin. That turned out to be an understatement, as the surgeon at the hospital later explained to her:

“He’s got double mandibular condyle fractures on both sides of his face,” meaning he broke his jaw in two places. “We’re going to need to go in, obviously, and do surgery and wire his mouth shut,” Siriani says the doctor told her.

Siriani’s dad has had to live in a nursing home ever since, fed through a feeding tube. She still doesn’t know exactly what happened that night. Every staff member had a different story. The stories changed. There was no apology. She filed a complaint with the California Department of Social Services, or DSS.

“I must have called the state once a week, for at least the first three months,” Siriani recalls. “And I was just always told, ‘We’re working on it. We’re working on it. We’re working on it.'”

It was a year before Siriani got an official report in the mail.

DSS did send out an investigator who cited the facility. He also fined the operator of the facility the maximum amount allowed by law: a mere $150. In comparison, the maximum penalty in a California nursing home is $100,000. “You know,” says Siriani, “a couple hundred dollars to these places is absolutely nothing.” But her life and her father’s life was “turned around forever.”

By then, Siriani had hired a lawyer. His investigators uncovered chronic under-staffing, poor training, and a known issue with the lock on the door her father passed through. The facility settled for an undisclosed sum. (And as part of the settlement, Siriani agreed not to name the facility publicly.)

Pat Leary is chief deputy director for the California Department of Social Services, the primary agency responsible for oversight of assisted living facilities. Leary acknowledges the criticism that $150 isn’t big enough to serve as a deterrent. As part of its annual budget proposal this year, the DSS suggested raising the fine, but that requires an act of the state legislature.

“Civil penalties are set in statute, and most of those statutes haven’t changed over time for many, many years.”

There is legislation pending that would address some of the issues raised by Siriani’s experience. AB 2236 would raise the maximum fine from $150 to $15,000. AB 1554 would require the DSS to investigate within one working day if the complaint alleges abuse or imminent danger and then report back within 10 days. [UPDATE: AB 1554 failed to make it out of the Senate Appropriations Committee.]

What’s less clear is how the agency’s 462 inspectors are going to meet that new standard if it’s signed into law. They’re not just responsible for the state’s 7,800 assisted living facilities, but all of the 66,000 facilities DSS oversees, including foster care homes.

“We issue thousands of citations in any given year,” Leary says. “The last year I had data was for 2012-13, we issued over 55,000 citations.” But, she adds, not all complaints are equal. “Understand it’s a complete range — from the most serious and extreme critical issues death and serious bodily injury — to not finding a parking place in front.”

Leary says there is no average time for processing a complaint — and no way to say, for instance, what the most common kinds of complaints are, or how long it typically takes to investigate a complaint.

“We don’t categorize, due to the antiquated nature of our technology. We don’t have a good data reporting system that gives us our most average complaint. But the ones that we clearly give the highest priority are ones that deal with immediate health and safety issues.”

If a DSS investigator uncovers evidence of a possible crime, a DSS spokesman says a referral would be made to the appropriate law enforcement agency — but the agency does not maintain statistics on the number of referrals. State Attorney General’s offices report they’ve gotten a few — at least since 2000, when a Congressional act gave them the jurisdiction to pursue these kinds of cases.

But in San Diego, the county district attorney’s office has not gotten referrals. Deputy District Attorney Paul Greenwood says the county DA’s office has not gotten any referrals. And he’s the one who would know. Greenwood has specialized in prosecuting elder abuse in San Diego for 18 years, unusual for a DA in California. He says he can’t think of a single case brought to his attention by the DSS.

But he’s quick to add all that may be water under the bridge now. A couple of months ago, he was invited to a stakeholders’ meeting — at the local DSS office.

“In their office!” Greenwood exclaimed. “First time I’ve ever been involved in one of those. At the table was the sheriff’s department, paramedics, the police department, attorney general, me, city attorney. I mean, in 18 years, I’ve never seen this happen before.”

Greenwood credits a change of personnel. Others suggest political pressure may have something to do with it: particularly, a series of articles published last fall by San Diego Union Tribune/Center for Health Reporting. “Deadly Neglect,” as the series was called, detailed 27 deaths in assisted living in San Diego County — deaths caused by neglect and abuse.

“It didn’t surprise me, on one hand,” Greenwood says of the reports, “but there were some things that were being revealed through these articles that even shocked my conscience, and I was hoping that someone would take notice. Well, they did!”

Indeed. The reports were so dramatic, they inspired a round of legislative reform in Sacramento not seen in 30 years. [UPDATE: The governor has signed two bills into law. Another 10 are still pending.]

Meanwhile, county supervisors, led by Diane Jacob, decided not to wait for the state to act. They gave Greenwood’s office $1.3 million dollars to launch a one-year pilot program to focus on assisted living facilities. It’s the only unit of its kind in a California county DA’s office.

When Greenwood started, he found it difficult to get the kind of tips that would lead to a criminal investigation, let alone prosecution. But over the years, he built up a network of sources. “By the end of year one,” he recalls, “I issued 16 felony cases. Well, this is year 18. We’ll probably have issued about 400.”

Under the pilot program, Greenwood expects to be swamped with leads shortly.

]]>http://blogs.kqed.org/stateofhealth/2014/08/11/crime-in-assisted-living-what-happens-after/feed/2RS11391_photo-hpfStacy Siriani's father suffered a serious injury while in an assisted living facility in San Diego. (Rachael Myrow/KQED)Online Information About Assisted Living Facilities Hard to Come Byhttp://blogs.kqed.org/stateofhealth/2014/08/05/online-information-about-assisted-living-facilities-hard-to-come-by/
http://blogs.kqed.org/stateofhealth/2014/08/05/online-information-about-assisted-living-facilities-hard-to-come-by/#commentsTue, 05 Aug 2014 12:30:04 +0000http://blogs.kqed.org/stateofhealth/?p=20532

Lorchid Macri, 70, says she couldn’t find any information online when she had to find an assisted living facility for her mother in California. (April Dembosky/KQED)

Lorchid Macri wasn’t sleeping. Her elderly mother was wandering out of the house in the middle of the night, forgetting to turn the stove off. Macri had to keep watch over her 24/7.

“Dementia is a cruel disease,” Macri says.

She says the stress of caring for her mother was overwhelming. It wasn’t until she landed in the hospital herself — losing the sight in her right eye for 10 days — that she was ready to confront the fact that it was time to place her mother in assisted living.

“It’s gut wrenching to put someone that you love and who has cared for you in a facility with strangers,” she says.

Macri lives in central Oregon. But she wanted to find a home for her mother in Southern California where all of her friends and extended family live. Her search started where all consumer searches start these days: on the internet. She wanted to make sure the places she considered had no complaints lodged against them, no violations for neglect or abuse.

“There’s nothing,” she says. “You cannot find anything.”

Macri would have had to travel to a regional state office in Southern California and request paper copies of these reports. But from her home in Oregon, California’s website proved useless.

“I was dumbfounded at the fact that there were no methods to see if there were any reasons that I would not want to put my mom in any of these facilities,” she says.

She says the lack of meaningful information made an already difficult decision even more painful.

“You’re placing this individual that you love in a situation where you can only hope and pray that they’re going to be safe, secure, and well cared for.”

About a dozen states in the U.S. — including North Carolina, Florida and Ohio — make details about facility violations readily available online. California lawmakers say it’s an embarrassment that a state with the technical genius of Silicon Valley is so far behind.

At a press conference in January, Assemblymember Susan Eggman (D-Stockton) introduced a bill, AB 1571, that would require the state to build an online rating system where consumers can compare facilities on quality.

“We should not depend on Yelp when a loved one needs help,” she said.

The bill is one of several proposed assisted living reforms currently pending at the State Capital. Lawmakers will vote on it this month, but it’s unclear if they –- or the governor –- will sign off on the million-dollar price tag.

“I don’t see how we afford not to do this,” Eggman says, though she conceded that the political will to back technology projects is lacking. “There’s always more needs than there is money. And the state’s encountered budget problems for awhile now. So upgrading technology is not at the top of anyone’s list.”

Prior Attempt ‘Mind-blowingly Bad”

This isn’t the first time the state has tried to build a consumer website for assisted living facilities. Several years ago, the Department of Social Services (DSS) received a grant to help collect information from facilities that could be posted online.

“The result was mind-blowingly bad,” says Tony Chicotel, an attorney with California Advocates for Nursing Home Reform, an advocacy group that monitors the assisted living industry and is backing more than a dozen reform bills.

The site only listed names and addresses of facilities. There were no details on services, cost, or past problems.

“For consumers, it was completely useless,” Chicotel says.

Part of the problem was resistance from the assisted living industry. Most facilities refused to provide information for a website, partly because the technology deployed by the Department of Social Services to collect the information was so bad. But facilities also objected to publishing anything about their rates, says Benson Nadell, program director for the San Francisco Long-Term Care Ombudsman Program.

“They want interested parties to call up and have an appointment with their marketing person,” he says, adding that some sweet-talking salesmen want to prey on peoples’ guilt around placing their parents in a facility. “It’s like buying a car, particularly the nice looking places. They are quite enticing. And suddenly, money is no object.”

Will Lawmakers Greenlight the Funding?

After more than eight years, the California’s Department of Social Services finally added a new feature to its website in June. It now lists the number of complaints and citations lodged against a facility, but doesn’t say for what.

“It lacks specificity,” Nadell says.

Nadell says a database is only as good as the information entered into it. And here California has another problem. Current law only requires inspections of assisted living facilities every five years — more frequently only if there’s a complaint. But there’s a constant backlog of complaints that haven’t been investigated. So a lot of helpful information isn’t even being gathered.

“Right now it’s pretty hopeless,” Nadell says.

The Department of Social Services says it’s trying. Chief deputy director Pat Leary says the agency wants to post more information online, but it’s hamstrung by outdated technology. The department uses Lotus Notes, a database program developed before the internet took off.

“We have an antiquated computer system that requires human beings to go in and collect data and create reports by hand,” Leary says.

A complete overhaul of the entire system is what’s really needed, advocates say, but the cost of that far exceeds what lawmakers are willing to spend.

So consumers like Lorchid Macri are basically on their own. She found a facility in San Bernardino that she thought would be okay for her mother. But it wasn’t.

“She lost 17 pounds in 6 months,” she says. “She was not showered daily as she was supposed to be. We often found her in room still in her nightgown at 2 or 3 in the afternoon.”

After two facilities in two years, Macri was fed up. She moved her mom back up to a place in Oregon.

“I did not want to see another facility in California, because I couldn’t research it,” she says.

Macri says she knows her mother is doing well now, because she’s stopped asking if she can come home.

]]>http://blogs.kqed.org/stateofhealth/2014/08/05/online-information-about-assisted-living-facilities-hard-to-come-by/feed/41LorchidLorchid Macri, 70, says she couldn't find any information online when she had to find an assisted living facility for her mother in California. (April Dembosky/KQED)